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Get and Sign Disabled Dependent Form
On your federal
Income tax return?
Yes
No
6. Is dependent employed?
6a. Date of Hire
6b. Number of hours employed per week.
6c. Describe nature of duties.
I certify that the above information is correct and authorize the release of medical information requested with respect to this certification.
________________________________________________
Signature of Subscriber
___________________________
Date Signed
TO BE COMPLETED BY ATTENDING PHYSICIAN
An unmarried dependent child, who is...
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